Healthcare Provider Details

I. General information

NPI: 1174477350
Provider Name (Legal Business Name): JESSICA RAE STOCK LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2026
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 NORTHLAND DR
MENDOTA HEIGHTS MN
55120-1288
US

IV. Provider business mailing address

3692 154TH ST W
ROSEMOUNT MN
55068-1791
US

V. Phone/Fax

Practice location:
  • Phone: 612-223-8898
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number306051
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: